Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.
A 24-year-old man presented with a 2-day history of a purpuric rash affecting his lower limbs, associated with fever, malaise and anorexia. He had fistulising, stricturing Crohn's disease with an end ileostomy and two enterocutaneous fistulae requiring long-term parenteral nutrition (PN) via a single-lumen Hickman line. His only medication was analgaesia and vitamin B12. He had not received regular steroids or immunosuppressive therapy for over 2 years.
On examination, he was febrile and tachycardic but not hypotensive. There were no cardiac murmurs and chest auscultation was unremarkable. His abdomen was soft and stoma output unchanged. A purpuric rash was visible on his lower limbs (figure 1). There was no meningism and examination of eyes, ears and throat was unremarkable.
Blood tests revealed haemoglobin 15.2 g/dL, white cell count 11.5 (neutrophils 9.5, eosinophils 0.8)×106/mL, platelet count 247×109/L, erythrocyte sedimentation rate 14 mm/h, C reactive protein 82.1 mg/L, sodium 122 mmol/L, potassium 4.6 mmol/L, urea 13.8 mmol/L, creatinine 89 μmol/L, bilirubin 21 μmol/L, albumin 28 g/L, alanine transaminase 133 U/L, alkaline phosphatase 673 U/L, international normalised ratio 1.4 and activated partial thromboplastin time 42 s. Chest X-ray and urinalysis were normal. An ultrasound and CT scan of the abdomen showed a fatty liver consistent with PN-associated liver disease but no other abnormalities.
Candida glabrata was isolated from Hickman line blood cultures after 24 h incubation. The line was removed and 2 weeks of intravenous caspofungin started. The rash resolved within 48 h of treatment and inflammatory markers normalised. A transthoracic echocardiogram, vasculitis screen and complement levels were normal.
Parenteral nutrition is an important risk factor for invasive candidiasis; Candida glabrata accounts for approximately 17% of positive cultures. Clinicians should remain alert to the possibility of disseminated candidiasis in susceptible patients.
The appearance of skin lesions can be the first clinical manifestation of acute disseminated candidiasis and this diagnosis should be considered in susceptible patients presenting in this manner.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.